WHY IT IS IMPORTANT

The Medicaid program is funded with both state and federal tax dollars. It is designed to pay for health care for low-income and vulnerable Floridians (children, pregnant women, disabled adults and seniors) who need care. When people get benefits they don’t deserve, or when providers are paid for services that were not supplied, it wastes your tax dollars and takes services away from those who need them.

WHAT IS MEDICAID FRAUD?

Medicaid fraud means an intentional deception or misrepresentation made by a health care provider with the knowledge that the deception could result in some unauthorized benefit to him or herself or some other person. It includes any act that constitutes fraud under federal or state law related to Medicaid. To report suspected Medicaid Fraud, please call the Attorney General toll-free at 1-866-966-7226. Find out if you are eligible for a reward. Callers may request to remain anonymous.

THINGS YOU CAN LOOK FOR

Upcoding

Providers bill Medicaid using codes that describe the amount of time spent with the patient. If a patient sees a health care provider for ten (10) minutes on a simple matter and the provider bills for an hour-long, complex visit, that is upcoding.

Unbundling

Some billing codes used by providers are all-inclusive and “bundle” several laboratory tests into one code. If the provider breaks the bundled code into several parts to achieve a higher reimbursement rate, that is unbundling. For example: A Lipid Panel is a laboratory test that includes three different component tests. Unbundling occurs when the three component tests are billed instead of the Lipid Panel.

WHAT FRAUD LOOKS LIKE

Most providers who commit Medicaid fraud fall into one or more of these categories:

billing for patients who did not really receive services,

billing for a service and/or equipment that wasn’t provided,

billing for items and services that the patient no longer needs,

overcharging for equipment or services,

concealing ownership or associations in a related company,

paying a “kickback” in exchange for a referral for medical services or equipment,

billing more than once for the same service,

using false credentials such as diplomas, licenses or certifications, or

ordering tests or prescriptions that the patient does not need.

HOW TO REPORT FRAUD

You can help protect your tax dollars by reporting suspected fraud by phone, through the Internet or by regular mail. You can do this without giving your name, but if you agree to give your name and other contact information, that helps the investigators to obtain future information.

Before you make a report, try to get as much information as possible, including:

the name of the person you suspect of committing fraud. This might be a person receiving medical benefits or a health care professional hospital, nursing home, or other facility that provides Medicaid services

the Medicaid ID number

the date of services

the amount of money involved, and/or

a description of the acts that you suspect involve fraud

WHAT YOU DO TO PREVENT FRAUD

Do not give your Medicaid card number to anyone except your doctor, hospital or other health care provider

Do not ask your doctor or other medical provider for medical care you do not need.

Be suspicious if you are offered free screenings or tests in exchange for your Medicaid card number.

Ask questions if someone wants you to have services or treatments that you feel you do not need. If necessary, get a second opinion from another health care provider.

Do not accept money or gifts from anyone who offers to buy medicine that you have received through Medicaid.

Those who report fraud may be entitled to a reward if they report a criminal case that results in a fine, penalty or forfeiture of property. To find out more, call the Attorney General at 1-866-966-7226. FS 409.9203 Rewards for reporting Medicaid fraud

112.3187 Adverse action against employee for disclosing information of specified nature prohibited; employee remedy and relief - may be cited as the "Whistle-blower's Act."

While committing significant resources to protect the public’s interest, the Attorney General’s Office will always welcome the assistance of the citizens in fighting against health care fraud. Under Florida’s False Claims Act, persons who blow the whistle on Medicaid Fraud are entitled to share in any funds recovered by the state. Please visit the Attorney General's Medicaid Fraud Control Unit page to report your suspicions of fraud or abuse.